Promoting Health and Wellbeing of Children and Families Through Relationship Based Interventions

Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. I aim to show how contemporary developmental science points us on a path to effective prevention, intervention, and treatment, with the aim of promoting healthy development and wellbeing of all children and families.

Saturday, January 27, 2018

A Conversation with Nadine Burke Harris: How Should Pediatricians Address Childhood Adversity?

Pediatrician Nadine
Burke Harris is a masterful storyteller. I learned in a conversation with her
at Wheelock College before her presentation for the Brookline, MA
organization Steps to Success, that before she decided
to become doctor, Dr. Burke Harris wanted to be an author. Only after the
smashing success of her TED talk: How childhood trauma affects health across a lifetime,
when she was approached by a literary agent, did she find her way to writing. Her newly released book The Deepest Well: Healing the Long-term Effects of Childhood Adversity is filled with engaging stories that
intertwine personal experience and scientific discovery. Now on the road
promoting the book, Burke Harris is able to put her storytelling skills to use
in spreading the important messages of her work.

In
the book, Dr. Burke Harris describes the convergence of two events. First,
while working at a clinic that she founded in a high needs, low
resourced community in San Francisco , she observed that
children with ADHD, asthma, and other common childhood illnesses had
experienced massive levels of adversity. Then fortuitously, a colleague showed
her the CDC- Kaiser Permanente co-sponsored Adverse Childhood Experiences (ACE) study,
that offers dramatic epidemiological evidence of the high correlation between 10 adverse childhood experiences and negative health outcomes both physical and
emotional. As an example of her skill at vivid communication, in describing this moment of discovery Dr. Burke made a "whoosh" sound to accompany the visual
depiction with movement of her hands that, "the top of my head blew off."

Now
Dr. Burke Harris is a woman on a mission to make ACEs screening an integral
part of pediatric care. The launch of her book tour coincided with the website
for this initiative NPPCACES (The National Pediatric
Practice Community on Adverse Childhood Experiences) going live. The hope is for all pediatricians to give parents a "de-identified" screen. Those with a high score go on to another level of care.

As
a pediatrician specializing in the developmental science of early childhood, I was interested
to learn from Dr. Burke Harris how the she sees the science of ACEs impacting
on the way we care for parents and infants.

Toxic
stress, defined as stress in the absence of safe, secure caregiving
relationships, is a mechanism by which adverse experiences get under our skin
and wreak their long-term havoc on our health.I wondered if the clinicians whose main task is to support these
relationships might be the front line of care, with the pediatrician as the
specialist.

While Dr. Burke agreed in theory she said, “we’re not there yet." She went on to explain, "The
medical specialist is the authority," She see the entry point for
integrating ACES as firmly embedded in the medical model. She does not want to
force pediatricians to take on the role of promoting relationships, which is
not what many have signed on for. As an example, she said that pediatricians will
more likely embrace screening for ACEs if they see that it will help in management
of asthma, revealing which patients may benefit more from decreasing adversity
than from treatment with bronchodilators. Once they see the high prevalence of
ACEs, as was demonstrated in the original study and has been replicated in
many, then they may come around to a focus on supporting relationships.

I
was also curious about the poignant stories in the book where she comes up
against resistance. At a meeting where she had to step out to pump breast milk
for her infant son, she returned to find people describing her as “that doctor
from San Francisco telling us that our kids are brain damaged.” While most
people depicted in her book find learning their ACE score to be deeply
empowering, a subset experience it as victimizing and blaming.

When
I raised the question of what might lead a person to have a negative reaction,
immediately Dr. Burke Harris gave an impassioned defense of screening to
address what she describes as a public health emergency. She likened the
problem of a negative reaction to a side effect of a life saving antibiotic. We
agreed that identifying a subpopulation that might have a negative reaction to
screening would mitigate this risk.

During
the Q&A following her talk, an audience member described how when she tried explaining ADHD as symptoms associated with adversity, she got pushback from
both parents and teachers. Dr. Burke Harris responded that we must dispel
misinformation and “shout our message from the rooftops.”

At
Montefiore Medical Center where ACEs screening has been implemented, pediatricians
explain to parents that higher ACE scores are tied to long-term impact on their child’s
health. But as Dr. Burke Harris herself described, when we feel threatened, the
thinking parts of our brain do not function well. Perhaps some of the people
who resist cannot hear this rational explanation.

As
I listened to her presentation following our conversation, the work of
neuroscientist Stephen Porges came to mind. His research shows that under
situations of overwhelming threat, rather fight or flight a third response of our nervous system, under
the influence of the primitive vagus nerve, takes over. Not
only does our thinking brain go “offline” but also the muscles of the middle
ear literally do not function normally. When people feel safe, the “smart”
vagus of the parasympathetic system comes online and we are able to listen and
connect.

As I'm sure Dr. Burke Harris would agree, screening
and safety need to go hand in hand. As I contemplated our conversation, I thought about the possibility of substituting the word
"listening" for the word "screening." At one point in the
book she writes, "By being open about ACEs with family and friends, people
are normalizing adversity as part of the human story." This phrase brought
to mind the work of Buddhist Thich Nhat Hahn on the universal experience of
suffering. He writes:

When
we listen with our whole being, we can diffuse a lot of bombs. . . . If there
is someone capable of sitting calmly and listening with his or her heart for
one hour, the other person will feel great relief from his suffering.

I
wonder if ACE screening is a form of communicating to parents, "I recognize your
suffering and I am here to listen." If so, then universal screening offers
a clear path to healing.

4 comments:

Part of the problem here is a sort of catch-22 which you noted in your email exchanges with me. Instead of hearing "I recognize your suffering..." parents these days hear "Your kids' problems are all your fault." Pharmaceutical companies are quick jump in and say the problem is entirely within the kids' defective brains.

In psychotherapy, the therapist can use empathy to counter the inherent paradox of "you need to parent differently, but you are blameless." In public forums, this is much harder to handle.

Yes the Polyvagal theory as described by Dr. Porges adds an important dimension to the question of how trauma comes to live in our bodies. It is in alignment with Ed Tronick's Still Face research showing that patterns of relating with primary caregivers become integrated into our relationships but with an emotionally unavailable caregiver, eg a depressed mother with a chronic "still face" these patterns of relating become maladaptive in our social interactions going forward.

I just finished reading The Deepest Well and despite everything I already knew about ACEs found it fresh and inspiring and loved her humor and examples of how she has learned to incorporate ACEs screening and support into her medical practices.

I'm a former family doctor who retrained as a somatic psychotherapist and then specialized in trauma therapies. Porges' work, freeze states, understanding attachment & development from these neurobiological perspectives - it all changes how we think of and understand health in such profound and inspiring ways.

I've specialized in chronic illness and see it from a similar view point as you and Burke Harris express - an altered physiological state reflecting a nervous system (and hence so many other systems) caught in fight / flight / freeze at the cellular / biological / physiological levels. It brings in so much hope - even as we continue to work with the resistance, shame and blame that it elicits in some.

I find this negative reaction to be very strong in the chronic illness community, so many of whom have been told their (often difficult-to-diagnose) symptoms or diseases are psychological or "all in their heads" if there is a history of trauma.

Thanks so much for sharing your conversation. I'm thrilled to see that you have a book out on these views of development :-). It's exciting to see this information coming into medical care, even if it is a slow process.

the baby connects

About Me

I am a pediatrician and writer with a long-standing interest in addressing children’s mental health needs in a preventive model. I have practiced general and behavioral pediatrics for over 20 years, and currently specialize in early childhood mental health. I am the author of The Developmental Science of Early Childhood:Clinical Applications of Infant Mental Health Concepts from Infancy Through Adolescence" ( 2017)"The Silenced Child:From Labels, Medications, and Quick Fix Solutions to Listening, Growth, and Lifelong Resilience" ( 2016) "Keeping Your Child in Mind: Overcoming Tantrums, Defiance, and other Everyday Problems by Seeing the World Through Your Child's Eyes"(2011) " I am on the faculty of UMass Boston Infant-Parent Mental Health Program, William James College, the Brazelton Institute, and the Austen Riggs Center.